Rare Complication After Spinal Fusion

Any surgery is done knowing there are risks involved. The most serious risk is death. But sometimes the unusual happens. In this case report, a 70 year-old-woman who had spine surgery ended up with a rare condition called man-in-the-barrel syndrome (MIBS). The surgeons involved in the case present what happened in order to help other surgeons be aware of such a complication.

Man-in-the-barrel syndrome (MIBS) presents as complete loss of movement in the arms. This symptom is referred to as brachial diplegia. She could feel pain but could not move in response to it. Her legs were unaffected, so she could move those freely.

Other symptoms associated with this problem include flat affect (no facial expressions), mild cognitive deficits (decreased mental function), and poor balance while walking. MIBS gives a patient the appearance of being confined within a barrel.

Her medical history included several spine surgeries for degenerative scoliosis (curvature of the spine) and lumbar stenosis (narrowing of the spinal canal). The scoliosis was causing her to become stooped forward (kyphosis). The stenosis was putting pressure on her spinal cord and spinal nerve roots causing back and leg pain.

Other pertinent information about her medical history included the fact that she had high blood pressure, elevated cholesterol, and low thyroid function. A year earlier, she had what’s known as a transient ischemic attack (TIA). This means some part(s) of the brain is temporarily deprived of blood supply (and therefore oxygen).

The first operation she had was a fusion from T11 down to S1. That means the spine was fused from the bottom of the thoracic spine down to the top of the sacrum. Postoperative complications from that procedure included infection, nonunion (fusion didn’t take), and spondylolisthesis.

Spondylolisthesis means there was a crack in the pars interarticularis, a supportive column of the vertebra. The crack opened and separated, allowing the vertebral body to slide forward over the vertebra below. The spinal canal was then compromised contributing to spinal stenosis. This positioning of one vertebra (displaced forward over the one below it) can pull on the spinal cord and/or spinal nerve roots causing painful symptoms.

She had a second surgery to stabilize the spine. This was done by performing an anterior lumbar interbody fusion at L45 and refusing the T11 to S1 segments. In addition, iliac screws were added to link the lumbar spine with the pelvis.

There were even more problems after this operation. This time, she developed a progressive kyphosis to the point that she could no longer stand up. The hardware at the L5S1 failed (probably due to the position of her body).

The third surgery was done to remove the hardware put in during the previous fusion operations. The surgeon took out the bone around the spinal nerve roots in a procedure called a laminectomy. Then, the surgeon placed screws from T3 all the way down to the ilium (pelvis). During this third operation, her blood pressure dropped requiring medication to increase the blood pressure.

She was also given a blood transfusion and cell saver blood. Cell saver blood refers to the fact that blood lost during the procedure was collected during and after the surgery using a device commonly known as the cell saver. Then it was reinfused into the body.

The brachial diplegia occurred right after a 30-minute episode of hypotension (very low blood pressure). All of this happened six hours after the surgery. She was tested right away with CT scan, MRI, and other contrast-enhanced imaging studies. All the findings were negative. There was no obvious cause of her symptoms. A cardiac workup was also within normal limits given her age and history with nothing to explain the paralysis.

Fortunately, the patient gradually returned to normal in all areas (muscle control, mental ability) with reduced pain and improved daily function. The authors suspect she developed this problem as a result of a loss of blood supply to the region of the brain that controls the arms. They suggest the area between the anterior and middle cerebral arteries supplying the temporoparietal region of the brain was the key area affected.

The underlying event leading to this complication was the sudden loss of blood pressure. Rapid fall in blood pressure can result in brain damage. Her previous history of high blood pressure probably contributed to the problem. Since her neurologic signs were normal right after surgery, they suspect the problem developed during recovery.

The prognosis for man-in-the-barrel syndrome is usually good. If the blood loss is identified early and treated right away, the condition is completely reversible. That’s why it’s so important for surgeons to be aware of this possible (though rare) adverse effect. Prognosis depends on how severe the blood loss is and how long it lasts. The sooner the blood supply can be restored, the more likely it is that the patient will experience a total recovery.

Optimal Treatment for Vertebral Burst Fractures

In this retrospective study, surgeons look back over the medical records and treatment results of 127 patients with an acute (recent) thoracolumbar burst fracture. Treatment for this condition isn’t cut and dry. There are still many questions about the best way to go: should the patient have surgery to stabilize the spine? Or can the problem be treated just as well with a nonoperative (conservative) approach?

The purpose of the study was to see how well patients did in the long run with conservative care. At the same time, the authors looked to see if the Load Sharing Classification, a method used to direct what type of surgery should be done, can also be used to predict if surgery is even necessary. If the score on the Load Sharing test does not indicate surgery and conservative care is the approach taken, what would the predicted long-term results be for nonsurgical treatment based on the total Load Sharing score?

Thoracolumbar burst fractures occur in the spine where the end of the 12 thoracic vertebrae meet the start of the five lumbar vertebrae. A high-energy load through the spine causes the vertebra to break or shatter into many tiny pieces. The danger of these fractures is that the bone fragments can shift and press into the spinal cord or spinal nerve roots causing temporary and even permanent neurologic damage. Burst fractures are most often caused by car accidents or by falls.

These types of fractures are grouped or classified using the Load Sharing Classification system already mentioned. There are three major groupings or ways to classify the fracture. The first is severity based on the amount of comminution (size and number of fractured pieces of bone). There are three levels of comminution or involvement: the number one represents little means there was less than 30 per cent of the bone affected. Between 30 and 60 per cent of bone involvement is labeled two or referred to as more. And more than 60 per cent of the vertebral body fractured is a subgroup labeled three and called gross.

The second Load Sharing Classification grouping is by apposition of fragments. This is a rating of how much the bone fragments have displaced (moved apart or separated). Minimal displacement is given a grade of one. Spread at least two millimeters apart but with less than half the vertebral body affected is a rating of two. And a wide displacement with more than half the body affected and spreading more than 2 millimeters qualifies as a three subgroup.

And finally, the Load Sharing Classification includes deformity correction. This is a measure of the severity of vertebral collapse and loss of vertebral body height. The severity of (spinal) canal compromise and the degree of neurologic deficit tell the surgeon whether the injury is stable or unstable.

Studies in the past have directed surgeons to use a posterior approach (incision from the back of the spine) when there is a mild comminution and an anterior approach (incision along the front of the body) when fractures are severely comminuted. This study evaluates the effectiveness of the classification scheme by looking at long-term results.

Patients included in the study were between 18 and 60 years old and had a burst fracture of any vertebrae between T11 and L2. All were treated with a nonoperative (conservative) approach. Anyone with burst fractures from osteoporosis, cancer, or other diseases causing a spontaneous fracture was excluded. Only medical records of patients with thoracolumbar burst fractures caused by high-energy compression from trauma were reviewed. Most of these were from falls or car accidents.

Scoring for Load Sharing Classification was done using X-rays and CT scans. Treatment included spinal positioning with pillows, soft rolls, or traction. The goal was to reduce the spine and realign it as much as possible. Vertebral fractures of this type often affect the front of the vertebral body. Collapse of this portion of the spine results in a kyphotic deformity. Kyphosis means the spine curves forward. If the treatment is not successful in maintaining spinal alignment during and after healing, the patient can become bent over as a result. This effect is referred to as loss of kyphosis correction.

Patients were kept on bedrest until the pain was tolerable. Anyone with neurologic impairment was given steroid therapy while in the hospital. Once the pain was reduced, they could walk and move about with a brace or body cast. The brace or cast was worn for at least three months.

Patients could return-to-work after the cast or brace was removed (approved by the surgeon). X-rays were taken when patients were admitted to the hospital with this injury and repeated for comparison at the end of three months, six months, one year, and at the final follow-up visit. Everyone was followed for at least three years. Some patients were seen for up to 12 years.

Various angle measurements were measured each time (e.g., vertebral wedge angle, lower intervertebral angle, and loss of kyphosis correction). Pain level, neurologic recovery, and work status were also recorded.

The recovery rate for patients was very high (93 per cent). The Load Sharing score taken from X-rays and CT scans right after the injury occurred did correlate with the angle of kyphosis (correction maintenance or loss) at the end of the study. Patients with good correction of the kyphosis deformity had less severe pain and better overall function (including return to work).

The results of this large study indicate that conservative care for thoracolumbar burst fractures is both safe and effective — even when there are neurologic signs of a severe injury. Judging from the scores on the Load Sharing Classification test and the final outcomes, it looks like this test can be used — not just for deciding what type of surgery to do, but also determining if surgery is even needed. Scores as high as a nine in patients with unstable fracture were treated successfully with conservative therapy.

A small number of patients treated nonoperatively eventually had to have surgery. Their back pain and poor functional outcomes required surgical intervention to stabilize the spine. Patients who opt for conservative care after traumatic thoracolumbar burst fractures can expect acceptable long-term results. Surgeons can use the Load Sharing Classification score to help guide patients in making the appropriate treatment decision regarding surgery versus conservative care.

Bone Cement Repair for Vertebroplasty Improved with Use of Iron Oxide Nanoparticles

People with osteoporosis (thinning bones) or certain types of cancers may end up with vertebral compression fractures, fractures in the discs of the spine. These fractures usually cause severe pain. The most common sign of someone with compressed discs is the “hunchback” that can occur as a result. To help manage the damage caused by vertebral compression fractures, doctors can do a vertebroplasty. This procedure involves the doctor injecting a special cement into the fractured bones. The cement mixture then hardens and protects the discs. This procedure doesn’t involve surgery as the cement is injected with a needle.

The usual cements used are calcium phosphate bone cements, which have been used for years in dental repairs and other orthopedic (bone) repairs. However, as easily as the cement can be used in some procedures, it can be difficult in the spinal area because of the holes in the bones and around. As a result, the procedure isn’t always effective. The authors of this study wanted to see if a new modified version of the bone cement, with iron oxide, would make the procedure easier and more accurate.

Researchers used a commonly used type of cement to be the control to compare with the new cement. They measured how long the cements took to set using a standard method. The researchers then tested the strength of the set cements, and how easily they were injected, and their chemical and microstructure were analyzed.

The results showed that adding the iron oxide to the cement increased both the initial setting times and final setting times, which made them easier to work with. When the cement sets too quickly, the doctors don’t have a lot of time to inject the cement and may become rushed. However, the length of time increased according to how much iron oxide was in the cement – the more the iron oxide content, the longer the setting time. In comparing the strength between the control cement and the new cement, the researchers found that this also increased with the amount of iron oxide in the cement. Injectability, the ability to inject the cement, was improved as well. With the cements with iron oxide, the injections were done more easily and with less force on the syringe than with the control cement.

One concern that the researchers had was that the iron oxide-enhanced cement may cause problems if a patient were to undergo magnetic resonance imaging (MRI), a test that requires magnets to scan images. They feel that this is not an issue but there are still come worries that the dyes, or contrast agents, used for the tests may make it difficult for radiologists (doctors who specialize in reading images) to tell the difference between cement and problems in the bone.

In all, the researchers reported that adding iron oxide to the powder base of the cement used for vertebroplasty improved the cement in setting times, strength, and ease of use. They recommended that further studies be done, looking at improving the design.

Traumatic Spondyloptosis of the Thoracolumbar Spine

The authors described five case studies of patients who suffered traumatic spondyloptosis of the thoracolumbar junction. This is a rare but severe injury. There is complete fracture dislocation of the spine. These injuries have the highest association with spinal cord injury of all fracture types. The thoracolumbar junction is involved in 15 percent of all spinal cord injuries. Three of the five patients were involved in high speed motor vehicle crashes. One sustained the injury when a building collapsed. The other was struck by a steel beam.

Four of the subjects had 100 percent subluxation in the sagittal plane. One had 100 percent subluxation in the coronal plane. The four subjects with sagittal plane disruption of their spinal column had complete spinal cord injury at the time of presentation. The patient with coronal plane disruption had incomplete spinal cord injury at the time of presentation.

Early stabilization of the spine allows early mobilization or activity. In the case of incomplete neurological injury, decompression and stabilization of the spine is hoped to improve neurological recovery as soon as possible The surgical procedure must allow for distraction of impacted vertebral bodies, restoration of alignment, and maintenance of alignment with stable internal fixation. All subjects underwent surgery to stabilize the spinal column in hopes of improving or restoring neurological function. Two subjects had single stage posterior fusion with pedicle screw and rod instrumentation. Three patients underwent staged posterior, then anterior fusion.

One patient could not be reached for follow up. Three who had complete spinal cord injuries had no improvement in neurological function. The patient with incomplete injury had improvement in lower extremity strength and was independently ambulating at six months following surgery. Other case reports have demonstrated similar findings and results with coronal plane spondyloptosis. The authors conclude that coronal plane spondyloptosis can be associated with incomplete spinal cord injury with the potential for favorable recovery of function.

Predictive Factors for Subsequent Vertebral Fracture After Percutaneous Vertebroplasty.

While percutaneous vertebroplasty is an effective tool in the treatment of vertebral compression fracture, twelve to 52 percent will have post percutaneous vertebroplasty, PVP, vertebral fracture.

The authors of the study were hoping to gain knowledge about risk factors for the development of post PVP vertebral fracture. They reviewed medical records of 508 patients who underwent PVP. Those with fractures from trauma and malignancies were excluded. They selected cases that had to undergo additional vertebroplasty following PVP. These 45 cases were divided up into two groups. Those with adjacent level fracture, and those with nonadjacent fracture. OVer 71 percent, or 35 of the cases were in the adjacent level fracture group. Fourteen cases were in the non-adjacent fracture group. They also chose a control group of 50 cases where there was no evidence of subsequent vertebral fracture following PVP.

Percutaneous vertebroplasty was done under fluoroscopy using an 11-gauge bone biopsy needle placed in the anterior third of the vertebral body for all patients. The bone cement was injected into the vertebral body until it reached the posterior quarter of the vertebral body, or when significant leakage occurred.

The authors reviewed various factors in order to determine risk fracture for post PVP vertebral fracture. Demographic factors such as age, and sex were evaluated. Constitutional factors included mean body mass index, mean body weight, and mean bone mass density. Spinal geometry evaluated adjacent range of motion, and degree of local kyphosis. The authors also looked at the mean volume of cement used. Lastly, they evaluated the effect of needle placement, either unilateral or bilateral.

The authors concluded that from the parameters they studied, risk factors for subsequent adjacent fracture following PVP was different than those for nonadjacent fractures. Slenderly built patients with osteoporotic bone and lower BMI were more at risk for sustaining an adjacent level fracture after vertebroplasty. Heavier patients with osteoporotic bone ran the risk of sustaining a nonadjacent fracture. Mobility gradient between neighboring segments was determined to be a risk factor for nonadjacent fracture. Intradiscal leakage of cement, rather than volume used, was predictive of adjacent level fracture.

Surgical Management of Posttraumatic Thoracolumbar Kyphosis

The authors reviewed available literature regarding current treatment methods for posttraumatic thoracolumbar deformity. In the United States alone, 10,000 to 17,000 people will have a spinal cord injury annually. Those that fracture their spine exceed 150,000 annually. As a result of improved medical care, more people are surviving these injuries. Disruption of the vertebral column and supporting ligamentous structures can result in posttraumatic spinal deformity. As a result, kyphosis, stenosis, instability, and scoliosis are becoming more common.

The most common late complaints following spinal injury include deformity such as kyphosis, increasing pain, and increasing neurologic deficits. New or increasing neurological deficits can be caused from increasing deformity, or from the development of posttraumatic syringomyelia. Twenty one to 28 percent of persons with spinal cord injury will develop a syrinx. Posttraumatic syringomyelia usually is identified by segmental pain, sensory loss, and progressive asymmetrical weakness. Kyphosis equal to or greater than 30 degrees increases risk for chronic pain and potential for neurological compromise. The authors feel that studies suggest that restoration or maintenance of normal spinal anatomy can prevent the development of posttraumatic syringomyelia and secondary neurological deficits.

Surgery to treat posttraumatic deformity is considered when there is axial back pain, pseudarthrosis or malunion, breakdown of levels above or below the original injury site, radiculopathy or increasing neurological deficit. When considering surgery, assessment of the degree of focal deformity is important. It is well known that a kyphosis deformity of 30 degrees or greater has an increased risk of chronic pain or progressive deformity. The authors note that half of patients treated with short fusion segments will eventually have progressive kyphosis.
Pseudoarthrosis that leads to instability will most likely benefit from combined anterior and posterior revision. Another option is a posterior approach with anterior interbody fusion. These procedures have shown to increase the chances of successful union. The authors suggest that anterior column support should be considered if fusion is extended to the sacrum due to high pseudoarthrosis rate otherwise.

Stiff or inflexible posttraumatic deformities are more difficult to correct and often require an osteotomy. There are several types of osteotomies that can be performed.

Results of surgical treatment of posttraumatic deformity are generally encouraging. Results are dependent on the type of initial injury, the time between the injury and the treatment of posttraumatic deformity, age, and medical condition of the patient. Surgical options include anterior approach, posterior approach, and a combined anterior and posterior approach. Regardless of the approach, the authors emphasize that thorough decompression of the neural elements is essential, as well as correction of the deformity.

While many patients have improved neurological function following surgery, up to 20 percent of patients may have worsening of neurological function. This risk can be decreased with spinal cord monitoring during surgery. Postoperative infection is also a potential complication of surgery.

Surgical Treatment of Unstable Thoracic Spine Injuries

Severe injuries to the thoracic spine occur with some car accidents. These high-energy injuries cause significant trauma to the spine. Surgery is needed to restore the vertebrae to a stable position. A major goal of treatment is to foster as much neurologic recovery as possible. In some cases, preventing paralysis may not be possible.

It’s not clear yet what kind of stabilization procedure is best for these traumatic spinal injuries. Rods placed alongside the spine have been used with disappointing results. Plates and screws along the posterior (back of the) vertebra give better correction.

In this study, screws were placed through the pedicles of the vertebrae. The pedicle is the area of the vertebra that is between the upper and lower spinal (facet) joints. Sometimes it is called the pars articularis.

The pedicle is stiffer than the vertebral body. It provides a place where the screws are less likely to pull out of the bone. Stainless steel screws were used because of their ability to resist fatigue failure while the bone graft healed. A large diameter screw 50 to 80 per cent the length of the vertebral body was selected.

Screws were placed in every pedicle on both sides of the vertebrae. The screws spanned from two to three segments above the area of injury to several segments below the lowest area of instability.

Using pedicle screws as anchors made it possible for the surgeon to distract, rotate, and place the broken and displaced vertebrae in proper alignment. Once the screws were in place, a rod to span the entire length of the surgical site helped unlock the overlapping facets.

The spinal deformity was reduced and maintained in 15 of the 18 patients treated with posterior-only pedicle screws. There were very few complications after the operation. This approach avoids doing an additional anterior or combined anterior/posterior fusion of the spine. Local bone graft is used to obtain a posterior-lateral fusion only.

Studies of the surgical treatment of serious, unstable thoracic spinal injuries are very limited. This study did not compare one technique to another. The authors just reported on this one method. Only short-term follow-up results are available.

So far, it looks like the use of posterior-only pedicle screws to stabilize the thoracic spine is a successful treatment option. Correction of the spine position and prevention of deformity was possible with this technique.

Case study of Patient with Giant Spiral Arachnoid Cyst Following Phenol Intrathecal Injection

Intrathecal injection of alcohol or phenol has been an effective pain management technique for patients who live with chronic pain. The injection damages the pain pathways, providing pain relief for up to several months. Although injection into the subarachnoid space can provide pain relief in up to 60 percent of patients, epidural injection is often preferred because of the side effects associated with subarachnoid injections. Side effects are usually sudden and are rarely delayed.

The authors of this article present the case study of a previously healthy 36-year-old woman who injured her thumb and arm in a fall, subsequently developing reflex sympathetic dystrophy. Following unsuccessful conservative treatment, as well as spinal and stellate ganglion blocks (injections into the sympathetic nerve tissue), the patient underwent an epidural injection in her upper thoracic region, the upper part of her mid-back, just below the neck area. She immediately developed a weakness in the left arm and leg and then went into respiratory arrest.

Following a 3-month period of intense rehabilitation, the patient was able to walk short distances with a cane although she still experienced some weakness in both legs. Two months later, she was readmitted to the hospital with increasing weakness and numbness of both legs, malnutrition, and pressure sores.

Assessment through magnetic resonance imaging (MRI) showed that the patient had increased spinal fluid pressure from T2 to T8 (vertebrae in the spine, labeled as T1 being the top thoracic vertebra and T12 is the lowest one) and a myelomalacia (softening of the spinal cord). Her doctors diagnosed myelopathy due to an arachnoid cyst. Following surgery to remove the cyst and to stabilize her cerebral spinal fluid pressure, the patient remained severely disabled.

The authors of this article note that complications of the injection are well known and include meningitis, as well as the spread of the agent into neighboring structures, including the spinal cord. However, arachnoid lesions of the spine was not a known complication. These lesions usually occur as the result of trauma, hemorrhage, parasitic infections, or other causes of inflammation. There are no standard treatment options. The usual options do include removing the lesion, draining the fluid, or providing a shunt for the fluid.

A Look at Patients with Spondylothoracic Dysplasia and Thoracic Insufficiency Syndrome

Spondylothoracic dysplasia (SD) is an inherited condition that results in dwarfism (short trunk), a prominent back of the skull, broad forehead, and wide nasal bridge, also results in severe respiratory problems from thoracic insufficiency syndrome. The skeletal deformities (ribs and spine) compress the area where the lungs should expand, making it difficult to breathe.

The authors of this study looked into the respiratory status of patients with SD, using x-rays and imaging tests, as well as pulmonary function tests. To do the study, the researchers identified 28 patients who fit the requirements for the study. Nine had been identified at birth while they were in the neonatal intensive care units; 8 died during the neonatal period due to respiratory complications. They were not included in the results because the patients died before computed tomography imaging (CT scan) could be done. The remaining patients, aged from 4 months to 9 years, completed the study. The researchers included 9 other patients who were older, ranging in age from 12 to 49 years.

The patients were seen in hospital emergency rooms, on average, 4.2 times during their first year of life. The visits were due to respiratory problems. This average number of visits dropped to 2 per year after the first year.

Evaluation of the patients showed that they had normal vital signs for their age (blood pressure, temperature, pulse), as well as appropriate respiratory rate, with clear lungs. Their abdomens protruded and rib cages were lower than normal. On average, the patients were in the 1.15 percentile range. Seventy percent of the patients were underweight for their height.

X-rays of the patients’ torso showed that the rib cage was asymmetrical and shortened to about 24.2 percent of predicted normal length. Five of the 20 patients had scoliosis (curvature of the spine). Computed tomography scans showed that the lung volume was 28 percent lower than normal. As well, the amount of air capacity, the forced vital capacity or FEV1, was 27.9 percent of the predicted normal value. The diaphragm was affected among the study patients, as was the trachea in 9 of the 20 patients.

The researchers discovered that the patients with SD who survived infancy were able to live relatively well with no progression of the abnormalities. Their body appeared to adapt to the lower respiratory function, although there is no clinical evidence as to how this happens.

A Look Back at the Results of Surgery for Scheuermann’s Kyphosis

In this study, surgeons take a look back and review the results of 78 patients who had surgery for Scheuermann’s kyphosis. The results of this study provide updated outcomes using current implant systems and surgical techniques.

Scheuermann’s kyphosis is an excessive forward curve of the thoracic spine. The thoracic spine refers to the mid-spine between the neck and the lumbar (lower) spine. Viewed from the side, the thoracic spine is normally curved like the letter C. The opening of the C faces the front of the body.

With Scheuermann’s kyphosis, too much curvature gives the person a hunchback appearance. Bracing is often used to help control the progression of this condition. But surgery may be needed if the curve gets worse despite conservative care.

The authors were interested in finding out how two different surgical methods compared. The first approach fused the spine from the front and back of the vertebrae. This was called a combined anterior-posterior arthrodesis. The second method fused the spine just from the back of the spine. This procedure is called a posterior arthrodesis.

They also measured loss of correction and junctional kyphosis. Junctional kyphosis refers to the formation of increased kyphosis above or below the fusion. The goal was to find risk factors that might contribute to these complications. Patients were followed for up to six years.

The results showed that complications were much more common in the group that had the combined anterior-posterior fusion. Loss of correction was more likely in patients having just the posterior fusion.

Junctional kyphosis occurred in up to one-third of the patients. This appeared to be linked with the angle of the pelvis. It was not the result of using a particular type of anchor (hook or screw) to fuse the spine.

Overall, the authors recommend the posterior arthrodesis over the combined anterior-posterior approach. More study is needed to find ways to prevent junctional kyphosis and other complications that require additional surgery.

Update on Scheuermann’s Kyphosis

Doctors from the Mayo Clinic provide this review and update on a condition called Scheuermann’s kyphosis. Kyphosis refers to a forward rounding of the thoracic spine. The deformity was first described by Dr. Scheuermann based on X-ray findings.

No one knows for sure yet just what causes this problem. Children between the ages 10 and 14 seem to be affected most often. Some reports suggest that boys are more likely than girls to develop Scheuermann’s. But other studies report equal numbers between males and females.

The cosmetic appearance of a humpback usually brings children to the doctor. Sometimes there are complaints of back, buttock, and/ or leg pain. Sleep disturbance from pain that wakes them up is also common.

X-rays are still used to identify and measure the curve. Scheuermann’s is diagnosed when the thoracic kyphosis is 40 degrees or more. Other findings include wedging along the anterior (front) portion of three or more vertebral bodies.

Disc spaces are narrowed and Schmorl’s nodes may be present. Schmorl’s nodes occur when the cartilage of the disc pushes through the vertebral body endplate and into the next vertebra.

Anyone with a curve that is 60 degrees and getting worse is a candidate for nonoperative care. Bracing can be used to control the deformity and restore the anterior vertebral height. Some children may need a series of body casts first before using a brace.

Surgery is advised when there is a progressive curve of 70-75 degrees. The kyphosis is rigid and does not correct (straighten), which causes an unacceptable cosmetic appearance. Kyphosis correction is achieved by lengthening the front of the spine. This is called an anterior release.

Shortening the posterior (back) column of the spine is the second step required. This can be done using a variety of fusion techniques described in detail. New technology has made it possible to fuse the spine without doing a combined anterior-posterior fusion procedure.

Fracture As a Complication of Kyphoplasty

Vertebral compression fractures (VCFs) are common in older adults who have osteoporosis (brittle bones). Treatment is usually conservative (nonoperative). But when pain persists, surgical procedures such as kyphoplasty or vertebroplasty may be advised.

Both procedures involve injecting cement into the broken vertebra. In kyphoplasty, a balloon is inserted inside the bone and inflated first. Then the balloon is removed, and the cement is squirted into the opening made by the balloon.

In this study, the incidence of vertebral fracture was compared between these two procedures. Other complications such as pain and cement leaks were also compared. X-rays were used to look for cement leakage and fractures at the adjacent (next) level.

The authors report that less cement was used with the vertebroplasty method of repair. It was only necessary to inject cement from one side with most vertebroplasties. This was compared with kyphoplasty, which often required injection from both sides of the bone.

Cement leakage occurred in about 11 per cent of all patients. There was no difference in leakage between the two methods. The location of the injection and the number of levels treated did not seem to make a difference in the amount of cement that leaked out.

Patients who had kyphoplasty were more likely to experience new VCFs. The fractures were located at the next level. All new cases were reported within three months of the original kyphoplasty.

The authors conclude that vertebroplasty used less bone cement, was less invasive, and has a lower risk of adjacent-level fractures. The amount of pain relief was just as much as with kyphoplasty. Careful surgical technique by an experienced surgeon using fluoroscopy (imaging X-rays) to perform the procedure is important in reducing complications.

Use of Image-Guided Technology in Spine Surgery

When the thoracic spine must be stabilized surgically, pedicle screws may be used. The pedicle is a portion of bone just below the facet joints of the spine. The pedicle connects the main body of the vertebra to the bony ring that protects the spinal cord. Using screws to hold the vertebrae in place is called instrumentation.

Placement of the screws is a technically challenging task for the surgeon. The screw can perforate (poke through) nerves, blood vessels, and even the spinal cord. Computer assistance to guide the surgeon has helped reduce these problems.

In this study, neurosurgeons at five major hospitals compare the use of two different image guidance systems. The first method used was virtual fluoroscopy (Fluoro-Nav by Medtronic).

The second navigation system was the new isocentric C-arm-based device (Iso-C). All patients were undergoing pedicle screw placement. Surgery was needed to stabilize the spine in 37 cases of trauma, degenerative disease, or bone tumor.

The authors used computer analysis to determine what a perfect screw placement would be. This was compared with CT scans showing the actual placement. The accuracy of screw placement was then compared using the two different navigational systems.

The type and amount of perforation with each system was identified. There was no difference in the overall rate of unintended or unsafe perforations between the two devices.

The risk of perforation increases anytime the pedicle is small. In those cases, even the smallest screw may be larger than the pedicle. The number of spinal levels treated with instrumentation did not increase the risk of perforation.

The authors concluded that both image-guidance systems provided safe and accurate results. The surgeon’s knowledge of anatomy and careful surgical technique aided by image guidance resulted in excellent outcomes.

Preventing Neurologic Injuries After Vertebroplasty or Kyphoplasty

Vertebroplasty and kyphoplasty are two similar surgical treatments for spinal factures caused by osteoporosis. In both these procedures, cement is injected into the fractured vertebral body. In the case of kyphoplasty, a balloon is inserted into the bone first. The balloon is inflated, removed, and then glue is injected inside the vertebral body.

The treatment is both safe and effective. But some cases of neurologic problems have been reported. A review of 14 cases of neurologic injury after kyphoplasty or vertebroplasty was reported in this study.

Some patients had severe back pain and leg weakness within 24 hours of the operation. Others developed these same symptoms more slowly (anywhere from three days to three months later).

Surgery was done right away for patients who reported severe back pain and weakness within 24 hours of the kyphoplasty. Anyone who couldn’t have surgery because of serious health issues was observed for 48 hours before initiating surgery.

Although this procedure has become very popular, surgeons should keep in mind there are serious complications possible. Infection, rib fractures, and blood clots top the list of possibilities. Cement oozing out of the bone and irritating the nerve structures is another potential problem. And the bone above or below the vertebral compression fracture (VCF) can also break or shatter.

The authors provide several suggestions for ways to prevent injury from either of these operations. First, the right patients must be selected for the treatment. Patients with burst fractures are not always good candidates for this operation.

Second, when this procedure is used for burst fractures, the balloon catheter is placed in the front of the bone. This seems to help contain the cement and keep it from oozing back out. Using a smaller amount of cement also seems to help.

Some surgeons have suggested the use of a bladder or lining to hold the cement in place. Others have proposed making the cement thicker and faster absorbing.

Surgeons should be reminded that neurologic complications can occur early or late with either of these operations. Recognizing the problem right away can help reduce the long-term effects.

Early Treatment for Thoracic Myelopathy Advised

There are many changes in the spine that occur with aging. Most affect the lower (lumbar) spine. Some affect the neck (cervical) spine. Much less often, but no less disabling, the thoracic spine is affected. The thoracic spine is in the middle between the cervical and lumbar spines. The ribs attach to the thoracic spine.

In this study, the results of surgery for thoracic myelopathy are examined for 132 patients. Myelopathy refers to any problem affecting the spinal cord. In most of these patients, pressure on the spinal cord was caused by changes in the spinal ligaments. These ligaments go along the entire length of the spine. Some patients had disc disease contributing to the problem.

Decompression surgery was done on all patients. This is the removal of bone from around the spinal cord or spinal nerves. Decompression takes the pressure off these nerve tissues. Everyone was tested before and after the surgery. Follow-up was at least two years.

The authors found that 75 per cent of the patients had myelopathy caused by hardening of the posterior longitudinal ligament (PLL). This ligament supports and connects the spine posteriorly (along the back side of the vertebrae).

Most of the patients (87 per cent) had good relief from their symptoms after the operation. The patients who had the best results were those who had symptoms of myelopathy the shortest amount of time.

The results of this study suggest earlier diagnosis and treatment of thoracic myelopathy is important for a good outcome. Recognizing thoracic myelopathy is a challenge. Establishing a correct diagnosis does not always happen until the condition has progressed.Delay in treatment leads to deterioration of the symptoms.

Causes of Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) refers to a condition of arm (and sometimes neck) pain, numbness, tingling, and weakness of the arms and hands. It is caused by pressure on the nerves and/or blood vessels as they pass through the neck and travel down the arm. TOS can affect one or both sides.

In this article, doctors from Turkey report on the case of a 22-year-old woman who was diagnosed with TOS after an accident. TOS can be caused by unusual anatomy, poor posture, tumors, or accidents. In this case, the young woman had both a congenital (present at birth) cause and a traumatic factor.

Her symptoms of numbness, tingling, and fatigue in the right arm were present before the accident. After the accident, she had similar symptoms in both arms. She also had a condition called hyperhidrosis in both hands. This is an increased amount of sweating. The symptoms were worse when she had her arms overhead or when carrying heavy things.

The condition was diagnosed with an X-ray and a magnetic resonance angiography (MRA). The X-ray showed a decrease in the natural lordosis (curve) in her neck. There was also an extra long transverse process on both sides at C7. The transverse process is a normal bony knob that sticks out from the side of the vertebral bodies.

The MRA is done with a dye injected into the bloodstream. It shows the blood shape and location of the blood vessels. In this case, they found a narrowing of the subclavian arteries on both sides.

The authors concluded TOS in this young woman was the result of both congenital and acquired causes. If she hadn’t reported similar symptoms before the accident, the diagnosis might have been delayed or overlooked. The more recent traumatic event made her condition worse.

Early Spinal Fusion is the Key to Success After Traumatic Kyphosis

Kyphosis, a forward curvature of the spine can occur after vertebral fracture. If the fracture isn’t treated properly or the bones don’t heal for some reason, this deformity can become a problem.

In this study, surgeons compare the results of two different ways to fuse the spine after post-traumatic kyphosis. Both methods were done from the front of the spine (anterior approach). The first group was fused with a plate-screw fixation. The second group had a double rod-screw fixation.

The same surgical team did all the operations. Deformed or compressed vertebrae were taken out completely. Any bone fragments left from the fracture were also removed. All patients were followed for at least five years. Neurologic status was monitored and compared before and after the surgery.

Measures used to compare these two methods included the amount of spinal correction, pain levels, and neurologic symptoms. Social, physical, and work function were also measured.

The authors report that a solid fusion occurred in all patients. Patients in both groups had equal amounts of pain relief. Correction rates were the same between the two methods of fusion.

The surgeons also looked at the factors affecting the results. They found that patients had the best results when surgery was done sooner than later. And the less severe the kyphosis deformity, the better the results.

The authors conclude anterior fusion with either fixation system works equally well. The key is to do the surgery as quickly as possible after the trauma. The short-term results of this operation were good. All patients were able to maintain their correction even after five years.

Diagnosing and Treating Symptomatic Thoracic Kyphosis

Surgeons from the Kyoto University School of Medicine report on a rare case of thoracic kyphosis causing serious problems for an 84-year old man. Thoracic kyphosis refers to an increased forward curve in the middle of the back. He was unable to walk more than 50 meters with a walker. Symptoms of dysesthesia in both legs kept him from walking farther. Dysesthesia is an unpleasant numbness caused by a normal, everyday activity like walking or touch to the bottom of the feet.

The patient had three operations to his spine in the two years before coming to the Kyoto University. Severe low back pain (LBP), right leg pain, and dysesthesia in both legs were not improved after any of the operations.

X-rays including special X-rays of the moving spine, CT scans, and MRIs were taken to help figure out what was wrong. The thoracic spine was bent so far forward that the spinal cord was stretched and draped over the vertebral bones.

Surgery to restore a more normal upright position of the spine was done with posterior fusion. Special rods were used to hold the spine in place. Special precautions and modifications were made during the operation due to the patient’s old age.

Six months later this gentleman could walk more than 400 meters with a single crutch. X-rays showed that the surgery was able to hold the thoracic spine in good alignment. The spinal cord was no longer stretched out.

The authors suggest elderly patients with walking disability and severe thoracic kyphosis may be suffering from a thoracic flexion myelopathy. Myelopathy refers to any disorder of the spinal cord. In this case, pressure and stretching of the spinal cord were causing problems. Posterior fusion of the spine with metal rods and a large bone graft was safe and effective for this patient and should be considered for others with this same problem.

Translaminar Screws for High Thoracic Fixation

When fusing bones of the spine together, surgeons can use hooks, wires, screws, rods, or plates. Recently special screws with superior strength called transpedicular screws have been in use. The location of the fusion has a large bearing in deciding which type of fixation to use.

In this study, translaminar screws were used to help fuse the upper thoracic spine (T1 or T2). This is a tricky area of the spine to fuse because the shape of the bones is changing from the cervical spine to the thoracic spine.

The shape, width, and size of the thoracic vertebrae all must be considered during fusion. The changes in anatomy at this spinal level make using transpedicular screws more of a problem. For example, the epidural space between the spinal cord and the vertebral bone is small. A screw long enough to help hold the spine in place could go right through this space.

Translaminar screws avoid this problem. From the way they are placed in the spine, there’s less risk of damage to the nearby nerves. Surgeons find the use of translaminar screws easier than transpedicular screws. They can see to thread the screw through the bone better than with the transpedicular screws.

Using MRIs, X-rays, and CT scans, seven patients having translaminar screw fixation were followed for at least one year. At the end of that time, none of the 19 screws placed in seven patients had broken or pulled out.

The authors conclude translaminar screws work well in patients with good bone and good alignment in the upper thoracic spine. Using transpedicular screws in this anatomically challenging area can be a problem. This group of patients will be followed much longer to see how long spinal stability lasts.

Finding the Right Spot To Feel The Transverse Process

Doctors and therapists treating the thoracic spine (middle of the back) have some special challenges. The anatomy of the thoracic spine is different from the cervical spine (neck) and the lumbar spine (low back). The bones of the thoracic spine are the transition units from cervical to lumbar spine.

In this study, physical therapists test a new model for finding the transverse processes (TP) of the thoracic spine. The TP is a bony extension out to the side of the vertebral bone. It connects to the rib on either side of the vertebrae. Restoring normal alignment and motion at this connection is important for some patients with shoulder, neck, or back pain.

But finding the exact spot of the TP can be difficult. It’s not close to the surface of the skin. Some examiners use the spinous process (SP) to help them find the TP. But the shape and direction of the SP changes from the top of the bottom of the thoracic spine. The spinous process is the bump you feel along the middle of your back. Using this landmark to locate the TP may not be reliable.

To find the best way to locate the TPs, researchers dissected 15 cadavers. They removed the soft tissues over the TPs and SPs. They inserted pins into the SPs and TPs of each thoracic vertebra. Then they used a digital caliper to measure the distances between these two points. They took into consideration how far apart the fingers have to be to feel contact points.

The authors report that if you find the SP and palpate (feel) just to the side of it, you’ll be on the TP of the vertebra one level above. This holds true throughout the thoracic spine.

This model replaces the previously used Rule of Threes model. The old model used the SPs to find the TPs. This method tried to adjust for the change in angle of the SP from vertebra to vertebra. The new model shows this is not necessary. However, this new model may not always apply to the last two thoracic vertebrae (T11 and T12) because of how much they vary in position from person to person.